The requirement to respect autonomy - The Royal New Zealand ...

BACK TO BACKAll people over 75 years with a five-yearCVD risk of >15% should be treated withstatins unless specifically contraindicatedSue Wells MBChB,MPH(Hons), PhDSection of Epidemiologyand Biostatistics, Schoolof Population Health, TheUniversity of Auckland,Auckland, New ZealandYES‘I don’t think about my age. It’s only a number.’—James Biggs (104-year-old resident in a Dallasretirement community)This commentary addresses three questionsrelated to the health of older people:• What do we want to achieve?• How applicable are CVD risk prediction tools?• What is the evidence for statin benefitand harm?Wells S. All people over 75years with a five-year CVDrisk of >15% should be treatedwith statins unless specificallycontraindicated—the ‘yes’case. J Prim Health Care.2010;2(4):330–332.Short answerOlder men and women—the grandparents ofour society, are treasures. As a group, they are atthe highest risk of CVD and, if they survive anevent, it may have considerable impact on theirquality of life and independence. Observationalstudies show that older people with favourableCVD risk factor levels are more likely to have ahealthier end of life as well as less life spent livingwith disability. Systematic reviews of primaryprevention trials demonstrate that statins willreduce CVD event rates by about 20% within fiveyears in people over 65 years, with little risk ofserious side effects. There is no good evidencethat this will simply change their mode of death(i.e. to cancer). Therefore, if elderly patients arethought to have a healthy life expectancy of fiveyears or more, those meeting guideline criteriafor statins should be offered them.What do we want to achieve?Ideally we want to delay the onset of illness anddisability, reduce the impact of morbidity andsupport our older patients to retain independenceand quality of life (QoL) as long as possible. Theprobability of death is 100%; the manner of livingprior to our dying is more negotiable.Cardiovascular disease (CVD) is a leading causeof death and healthy life years lost in NewZealand. 1 While having a heart attack and dyingin your sleep may seem to be a good way to go,many people will not die in this manner. Theprevalence of having had (and survived) a CVDevent rises exponentially after retirement age inNew Zealand; 35% of 75-year-old women (45% ofmen) and 45% (50% of men) by the age of 80 yearswill have suffered an event. 2 The QoL for thosefollowing a myocardial infarction or stroke isBACK TO BACK this issue:Sue WellsDerelie ManginWhile evidence can help inform best practice, it needs to be placed in context.There may be no evidence available or applicable for a specific patient withhis or her own set of conditions, capabilities, beliefs, expectations and socialcircumstances. There are areas of uncertainty, ethics and aspects of care for whichthere is no one right answer. General practice is an art as well as a science. Qualityof care also lies with the nature of the clinical relationship, with communication andwith truly informed decision-making. The Back to Back section stimulatesdebate, with two professionals presenting their opposing views regarding a clinical,ethical or political issue.330 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE